Valvular Heart Disease Management and Intervention

The diagnosis and estimation of severity of valvular disease can usually be made by a well done history and physical examination. We now have a wealth of noninvasive techniques capable of imaging the heart and the great vessels. With Doppler echocardiography and magnetic resonance imaging we are beginning to develop methods that can measure pressures and flow. All of these advances have duplicated to a large extent the information obtainable in the past only from cardiac catheterization and angiography. In some instances, in aortic and mitral stenosis, for example, echo-Doppler evaluation is so good that catheterization is rendered unnecessary. The decision to send patients to surgery without catheterization is especially secure when the valvular obstruction is very severe. When the gradient is only moderately increased, then estimation of severity depends on flow, and in many cases these patients are sent to catheterization before surgery is recommended. With regurgitant lesions there is less confidence with noninvasive techniques that the severity is always correctly estimated, and therefore catheterization and angiography are more often necessary before sending the patient to surgery. At the present time cardiac catheterization and angiography are required 1) whenever there is an inconsistency between the clinical picture and noninvasive information, for example, the symptomatic patient with aortic stenosis who has mild-to-moderate aortic stenosis by echo-Doppler techniques, and 2) whenever additional information not obtainable by noninvasive techniques is necessary, for example, the need to know the status of the coronary arterial circulation. Noninvasive techniques have not in any way replaced a good history and physical examination. A large part of the decision to send the patient with valvular disease to surgery depends on the history. The physical examination can be used to make the diagnosis of the type of valve disease present and can give a good estimation of its severity. Most importantly, a good history and physical examination tell the physician what still must be found out about the patient and therefore allow selection of the proper studies that will best provide the necessary information. (Circulation 1991;84[suppl I]:I-259-I-264)